Contingency Management Questions: Answered

Stopping drug use isn’t the most challenging part of recovery. Anyone can quit for a day, a week, a month; ask a cigarette smoker. Staying off drugs is much harder. 

One of the most effective ways to bolster sobriety and keep people in treatment for a substance use disorder (SUD) is contingency management (CM). 

Although CM is an evidence-based and drug-free treatment, it is seldom used because many critics object on ethical grounds. Most health insurance plans—including Medicaid, which paid for 21% of all SUD treatment in the US in 2014—do not cover it. 

What is contingency management?

Contingency management is based on the principle that when positive behavior is rewarded, individuals are more likely to continue that behavior. For example, paying a salesman a bonus for meeting or exceeding sales targets is a form of CM. So is a gold star in kindergarten for perfect attendance. 

In SUD rehab, CM rewards attendance at therapy or continued abstinence, as confirmed by negative drug tests: breathalyzer, blood, or urinalysis. 

In CM, rewards vary from:

• A slip of paper with a brief congratulation on it, such as “Good job!”
• A voucher for or toward an item from a VA canteen.
• A chance at a larger prize (such as a coffee maker or Blu-ray player).
• Cash (usually $1, with a rare top prize of $100). 

A reward could also be a privilege or trust. 

For example, some people with opioid use disorders take maintenance medications such as methadone or buprenorphine (Suboxone) to facilitate rehab by preventing withdrawal or reducing cravings. 

Such medications are closely controlled to prevent abuse. Methadone is normally dispensed at a clinic or physician’s office once a day. Buprenorphine prescription is a little less rigid. A client in CM might be allowed to take home a few days’ supplies of medication.  

All of this is contingent on continuing clean drug tests. At least some of the rewards may be cumulative; one positive drug test will send them back to square one. 

Why is contingency management seldom used?

Although studies show that contingency management works, it has a public relations problem among government officials, law enforcement, the judiciary, and even addiction specialists. Any SUD treatment plan that doesn’t follow a simplistic “just say no” abstinence message is suspected of encouraging addiction.

It’s mainly the cash or prize aspect that bothers CM critics. They feel it is wrong—morally or ethically—to bribe people to do something they should be doing anyway: getting and staying sober and drug-free. 

Other critics say the program is too expensive. Early programs awarded abstinent clients as much as $1,000. (The cost is now $200 or less per client over the course of treatment. The cost of the United States’ current level of substance abuse is much higher.)

In 2018, NIDA estimated the cost of drug addiction to society at $600 billion—not counting an additional $300 billion for tobacco—or approximately $1,835 for each person in the US in increased healthcare costs, crime, and lost productivity. 

Why the VA uses contingency management

At least three agencies of the federal government, not known for overlooking the moral or ethical dimension of government policies or spending, do accept contingency management as a safe and effective treatment for SUD: 

• The National Institute on Drug Abuse (NIDA). 
• The Substance Abuse and Mental Health Services Administration (SAMHSA).
• The Department of Veterans Affairs (VA). 

Since 2011, the VA has been expanding access to contingency management (CM) for substance abuse clients in its intensive outpatient programs. The programs typically last 12 weeks.  

The Veterans Canteen Service (VCS) supports VA’s CM programs with an annual contribution of $100,000 for voucher coupons.  

One reason the VA aggressively added CM is because veterans with stimulant use disorders (cocaine, methamphetamine, ADHD drugs) have fewer treatment options available than opioids or alcohol. There are no medication-assisted treatments (MAT) approved for stimulants.

Contingency management has had a high success rate with veterans. Between June 2011 and January 2015:

• 2,060 veterans participated in the VA’s contingency management program.
• They attended more than 50% of their scheduled sessions.
• They tested negative for their target substance 91.1% of the time.

According to a September 2021 report, the number of patients who had used the program had more than doubled to 5,600, and the percentage of negative tests was 92%. At least 110 VA centers now offer CM. 

Another reason the VA adopted CM was that it is flexible. It can be used in conjunction with other treatments, including:

• Cognitive-behavioral therapy. A type of psychotherapy or talk therapy that teaches individuals how to recognize and change negative thinking and find healthier coping mechanisms.
• Motivational interviewing. A type of talk therapy in which the therapist guides the client to accept the need to change and to want to change.
• Medication-assisted treatment. In alcohol and opioid rehab, MAT drugs may be used to prevent cravings and alleviate withdrawal symptoms so the clients can recover. 
• Biofeedback Therapy
• Aftercare. What the client does after leaving inpatient or residential care to maintain sobriety and abstinence is aftercare or continuing care. It often includes some therapy, exercise, and peer fellowships such as Alcoholics Anonymous or SMART Recovery. 

Concerns about contingency management

One concern of critics is that they don’t see how CM can encourage abstinence. Addiction is a chronic brain disease that changes the brain. CM incentives are mostly token items. 

True, but people in CM want to change. The token may be more important as a symbol of their success.

Addiction is also a habit, albeit a bad one. One way to strengthen the resolve to abstain is by creating new habits; CM is a new habit.

Here are some other concerns about contingency management: 

Does Contingency Management encourage gambling? 

Not according to any published study. Separate studies in 2010 and 2015 found that CM does not increase gambling and may decrease it. Why should it? The client isn’t risking anything to win a prize. 

People with existing gambling addictions are usually excluded from CM, however. 

Do clients exchange CM prizes for drugs? 

No. Most prizes aren’t worth much or would interest a drug dealer or shopkeeper. Besides,  if the clients fail a drug test, the prizes stop. For whatever reason, studies show they don’t. 

Does CM take away internal motivation to change?

No. However much they want the prize, people don’t usually abstain and go to therapy just for the prize. Even when they do, as CM continues, abstinence is reinforced.

Does substance abuse resume when CM ends?

It might. Every form of substance abuse treatment has a high relapse rate. According to the best evidence currently, addiction has no permanent cure. 

Rehab works best for those who:

• Learn to cope with cravings and temptations after rehab ends. 
• Avoid triggers (people, places, situations associated with their former substance abuse).
• Continue therapy.
• Join a peer fellowship group. 

Contingency management, like other therapies, gives clients a good start. 

Sources

1. ncbi.nlm.nih.gov – Voucher-Based Contingency Management is Efficacious but Underutilized in Treating Addictions
2. thenationalcouncil.org – Americans with Mental Health and Substance Abuse Disorders: The Single Largest Beneficiaries of the Medicaid Expansion 
3. va.gov – VA Homeless Programs: Contingency Management
4. drugabuse.gov – Contingency Management Interventions/Motivational Incentives (Alcohol, Stimulants, Opioids, Marijuana, Nicotine) 
5. drugabuse.gov – Is drug addiction treatment worth its cost?
6. worldometers.info – United States Population
7. store.samhsa.gov – Enhancing Motivation for Change in Substance Use Disorder Treatment: Updated 2019 
8. va.gov – Contingency Management for Supporting Substance Use Treatment and Recovery: An Innovative Practice in VHA Homeless Program Operations
9. sunshinebehavioralhealth.com – What to Expect from an Intensive Outpatient Program 
10. vacanteen.va.gov – Veterans Canteen Service (VCS)
11. ncbi.nlm.nih.gov – The national implementation of Contingency Management (CM) in the Department of Veterans Affairs: Attendance at CM sessions and substance use outcomes
12. npr.org – To Combat Meth, California Will Try A Bold Treatment: Pay Drug Users To Stop Using
13. nytimes.com –  This Addiction Treatment Works. Why Is It So Underused? 
14. mayoclinic.org – Cognitive behavioral therapy
15. samhsa.gov – Motivational interviewing: An effective technique in recovery support 
16. samhsa.gov – Medication-assisted treatment
17. gcse.asu.edu – Substance Abuse Aftercare Treatment Continuum Of Care
18. newsinhealth.nih.gov – Breaking Bad Habits: Why It’s So Hard to Change
19. health.uconn.edu – Contingency Management: Frequently Asked Questions
20. ncbi.nlm.nih.gov – Prize-based contingency management is efficacious in cocaine abusers with and without recent gambling participation
21. journals.lww.com – Complimentary Forces of Change: Contingency Management and Behavioural Momentum as Treatments for Problematic Gambling
22. drugabuse.gov – Drugs, Brains, and Behavior: The Science of Addiction Treatment and Recovery